Nurs 6665 week 2 Assignment 1: Evaluation and Management (E/M)

Assignment 1: Evaluation and Management (E/M)

Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.

For this Assignment, you will review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5 to ICD-10.

To Prepare
Review this week’s Learning Resources on coding, billing, reimbursement.
Review the E/M patient case scenario provided.

The Assignment
Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.
Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.

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Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.
Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

By Day 7 of Week 2
Submit your Assignment.

Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:

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Click the Week 2 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
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Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn1+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.

Pathways Mental Health

Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5 and ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document.
IDENTIFYING INFORMATION Identification was verified by stating of their name and date of birth.
Time spent for evaluation: 0900am-0957am

CHIEF COMPLAINT “My other provider retired. I don’t think I’m doing so well.”

HPI 25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.

Today, the client denied symptoms of depression, denied anergia, anhedonia, motivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. The client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. The client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. The client reports increased irritability and easily frustration, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of a previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. The client denied any current binging/purging behaviors, denied withholding food from self, or engaging in anorexic behaviors. No self-mutilation behaviors.

DIAGNOSTIC SCREENING RESULTS Screen of symptoms in the past 2 weeks:

PHQ 9 = 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

GAD 7 = 2 with symptoms rated as no difficulty in functioning
Interpreting the Total Score:
Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety

MDQ screen negative

PCL-5 Screen 32


• Entered mental health system when she was age 19 after being raped by a stranger during a house burglary.
• Previous Psychiatric Hospitalizations: denied
• Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015
• Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing)
• Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records

SUBSTANCE USE HISTORY Have you used/abused any of the following (include frequency/amt/last use):

Substance Y/N Frequency/Last Use
Tobacco products Y ½
ETOH Y last drink 2 weeks ago, reports drinks 1-2 times monthly one drink socially
Cannabis N
Cocaine Y last use 2015
Prescription stimulants Y last use 2015
Methamphetamine N
Inhalants N
Sedative/sleeping pills N
Hallucinogens N
Street Opioids N
Prescription opioids N
Other: specify (spice, K2, bath salts, etc.) Y reports one-time ecstasy use in 2015

Any history of substance-related:
• Blackouts: +
• Tremors: –
• DUI: –
• D/T’s: –
• Seizures: –
Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings


The client was raised by adoptive parents since age 6; from a Russian orphanage. She has unknown siblings. She is single; has no children.
Employed at local tanning bed salon
Education: High School Diploma
Denied current legal issues.

• Suicidal Ideas or plans – no
• Suicide gestures in past – no
• Psychiatric diagnosis – yes
• Physical Illness (chronic, medical) – no
• Childhood trauma – yes
• Cognition not intact – no
• Support system – yes
• Unemployment – no
• Stressful life events – yes
• Physical abuse – yes
• Sexual abuse – yes
• Family history of suicide – unknown
• Family history of mental illness – unknown
• Hopelessness – no
• Gender – female
• Marital status – single
• White race
• Access to means
• Substance abuse – in remission

• Absence of psychosis – yes
• Access to adequate health care – yes
• Advice & help-seeking – yes
• Resourcefulness/Survival skills – yes
• Children – no
• Sense of responsibility – yes
• Pregnancy – no; last menses one week ago, has Norplant
• Spirituality – yes
• Life satisfaction – “fair amount”
• Positive coping skills – yes
• Positive social support – yes
• Positive therapeutic relationship – yes
• Future-oriented – yes

Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied a history of self-mutilation behaviors

Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence, however, the risk of lethality increased under the context of drugs/alcohol.

No required SAFETY PLAN related to low risk

MENTAL STATUS EXAMINATION She is a 25 yo Russian female who looks her stated age. She is cooperative with the examiner. She is neatly groomed and clean, dressed appropriately. There is mild psychomotor restlessness. Her speech is clear, coherent, normal in volume and tone, has a strong cultural accent. Her thought process is ruminative. There is no evidence of looseness of association or flight of ideas. Her mood is anxious, mildly irritable, and her affect is appropriate to her mood. She was smiling at times in an appropriate manner. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her insight is good.

CLINICAL IMPRESSION Client is a 25 yo Russian female who presents with a history of treatment for PTSD, ADHD, Stimulant use Disorder, in remission.
Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal symptoms, has somatic concerns of GI upset and headaches.
At the time of disposition, the client adamantly denies SI/HI ideations, plans, or intent and has the ability to determine right from wrong and can anticipate the potential consequences of behaviors and actions. She is at a low risk for self-harm based on her current clinical presentation and her risk and protective factors.


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TREATMENT PLAN 1) Medication:
• Increase fluoxetine 40mg PO daily for PTSD #30 1 RF
• Continue with atomoxetine 80mg po daily for ADHD. #30 1 RF

Instructed to call and report any adverse reactions.

Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful

2) Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained.

Not to drive or operate dangerous machinery if feeling sedated.

Not to stop medication abruptly without discussing with providers.

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings.

Discussed how drugs/ETOH affects mental health, physical health, sleep architecture.

3) Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.

4) Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

5) Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation.

6) RTC in 30 days

7) Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results

Patient is amenable with this plan and agrees to follow the treatment regimen as discussed.

• Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.
• Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options.
• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.]

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Diagnostic Impression: Post-traumatic stress disorder with ADHD, F43, F90-F99

Complete, accurate information is essential for developing accurate diagnoses and assigning them to DSM-5 and ICD-10 codes. Subjective and objective data should be obtained to support DSM-5 and ICD-10 codes. The other information needed to support DSM-5 and ICD-10 coding is mental status examination. Psychiatric mental health nurses should undertake a comprehensive mental status examination to reach an accurate diagnosis aligned with DSM-5 and ICD-10 coding. The mental status examination will guide the treatment interventions and the billing process. Diagnostic investigations should also be documented to support DSM-5 and ICD-10 coding. Diagnostic and laboratory investigations are essential in facilitating the development of accurate diagnoses. They also rule out potential medical conditions that might be contributing to the problem (Dodd, 2021). Information about the adopted treatment should be provided to guide reimbursement decisions for the healthcare providers and institutions.

The provided scenario is missing some pertinent information needed to narrow the client’s coding and billing. One of the data relates to the client’s behaviors. The psychiatric mental health nurse should provide detailed information about the character of symptoms and behaviors. Information such as symptom duration, factors that alleviate and aggravate them should be obtained. Information about the effect of the symptoms on the social and occupational functioning of the client is also lacking. Mental health disorders have adverse effects on patients’ levels of functioning and productivity. The nature of impaired functioning and productivity is crucial in determining the most appropriate diagnoses and DSM-5 and ICD-10 billing. The psychiatric mental health nurse should have explored the effects of the symptoms on functioning to determine the precise cause of the problem. The case study also lacks information about the laboratory and diagnostic investigations that were considered in determining the cause of the problem (Wright, 2020). For example, information including blood tests and radiological examination should have been provided to rule out any pathologies contributing to the problem.

Several strategies can be adopted to improve documentation that supports DSM-5 and ICD-10 coding and billing. One of the strategies is creating an organizational culture characterized by learning from mistakes. The organization should encourage the staff to identify documentation errors and analyze the factors that led to them and how to prevent their occurrence in the future. Learning from errors will promote continuous improvement in documentation practices, hence, the efficiency in the care processes. The second strategy that can be adopted to improve documentation is encouraging compliance with the billing requirements and policies. Healthcare providers should be encouraged to ensure their adherence to the developed guidelines for documentation. Compliance will minimize the risk for errors, which leads to accurate coding and billing for the services offered in the institution. Healthcare technologies can also be incorporated into the care process to minimize errors in documentation. Technologies such as integrated electronic health records will enable healthcare providers to perform regular checks on the accuracy of information (Lorenzetti et al., 2018). As a result, technologies will enhance the efficiency of documentation in the organization.


Dodd, S. (2021). A Critical Evaluation of the DSM-5 as a Taxonomical Information Organisation Tool for Psychiatry.

Lorenzetti, D. L., Quan, H., Lucyk, K., Cunningham, C., Hennessy, D., Jiang, J., & Beck, C. A. (2018). Strategies for improving physician documentation in the emergency department: A systematic review. BMC Emergency Medicine, 18(1), 1–12.

Wright, A. J. (2020). Conducting Psychological Assessment: A Guide for Practitioners. John Wiley & Sons.